Meal Prep is all about organization and multitasking life, so we have put together a guide to meal prepping in 2018 which includes the meal prep essentials we stock up on for a swift and stress-free meal prep. If meal prep is on your list of New Years Resolutions: 1. Woohoo! 2. This post is…
Let’s give the Office of the National Coordinator (ONC) credit for trying. In what’s arguably the first significant piece of policymaking, the newly Republican HHS issued a draft Trusted Exchange Framework and Common Agreement (TEFCA) that aims to implement the massively bipartisan 21st Century Cures act mandate to end information blocking. Are they succeeding?
Why should you care? After almost a decade and many tens of $billions spent on health information technology, neither physicians nor patients have access to a longitudinal health record, transparency of quality or cost, access to independent decision support, or even the ability to know what their out-of-pocket cost is going to be. After eight years of regulation, precious little benefit has trickled-down to patients and physicians. This post looks at the TEFCA proposal from the patient experience perspective.
The patient perspective matters because, under HIPAA, patients do not have choice about how our data is accessed or used. This has led to information blocking as hospitals and EHR vendors slow-walk the ability of patients to direct data to information services we choose. Patients lost the “right of consent” in 2002. This puts a regulation-shy administration in a quandary: How do they regulate to implement Cures, when current HIPAA and HITECH-era regulations give all of the power to provider institutions bent on locking-in patients as key to value-based compensation?
As regulations go, the draft TEFCA is an interesting design. It’s “voluntary” but it tries to consolidate as much power as possible into a single, ONC selected, private Recognized Coordinating Entity (RCE). The ONC / RCE hybrid is like the nationalized health record systems in England or other rich nations: patients are tracked across all participating providers; a government-controlled entity collects personal information, and they control who gets to access your information. The big question is, do patients really have a choice?
6.1.6 Consent. If and to the extent that Applicable Law requires that an individual’s consent to the Use or Disclosure of his or her EHI, the Participant of a Qualified HIN (or the End User of such a Participant) that has a direct relationship with the individual shall be responsible for obtaining and maintaining the consent of the individual (each a “Qualified HIN’s Consenting Individual”) consistent with the applicable requirements. Each Qualified HIN shall specify such responsibility in its Participant Agreements. Each Qualified HIN shall require its Participants to provide the Qualified HIN with a copy of each consent of a Qualified HIN’s consenting individual and the Qualified HIN shall maintain copies of such consents and make them available electronically to any other Qualified HIN upon request.
suggests that HIPAA’s lack of consent means you can’t opt-out whereas on page 43:
7.2 Individual Requests for No Data Exchange. Each Qualified HIN shall provide a method for individuals who do not wish to have their EHI exchanged and post instructions on its public website for both recording and communicating such requests to the Qualified HIN at no charge to the individuals. Each Qualified HIN shall process all requests from individuals or from Participants on behalf of individuals in a timely manner and ensure that such requests are honored by all other Qualified HINs on a prospective basis. As a HIPAA Business Associate, the Qualified HIN must also enable a Covered Entity to process the request consistent with the right of an individual to request restriction of Uses and Disclosures.
the right to opt-out is not qualified by HIPAA (emphasis added).
The voluntary aspect of TEFCA does allow patients to avoid surveillance if they can find providers that will treat them without requiring ID and maybe also avoid sharing information with the RCE Framework. HIPAA Covered Entities (hospitals, medical practices, labs,…) would still be subject to requests for patient-directed exchange such as specified by HEAlth Relationship Trust (HEART), but TEFCA is silent on this patient-centered alternative.
An optimistic interpretation of the draft TEFCA suggests a good patient experience with every provider giving every patient a choice of surveillance they don’t control (a kind of auto-pilot for privacy) vs. directed exchange based on policies they inherit from any source they trust. Policies they can change if they choose. Patient-directed exchange would prove safer for some patients and riskier for others but, other than the added engagement needed to rarely manage consents, the user experience would be the same for either choice. Many patients will have some records in both systems but the patient-directed system would, logically, have more complete records because it could aggregate records accessed from the RCE Framework with the more sensitive records accessed via patient-directed exchange.
A pessimistic interpretation of the draft TEFCA would have ONC allow a more complicated user experience for patient-directed exchange. Providers would be able to ignore HEART essentials like Dynamic Client Registration and Refresh Tokens [page 41]. They would be allowed to delay patient-directed access by days. They could make the process of registering a patient’s HEART authorization server different for each provider, etc… It all depends on how ONC decides to interpret information blocking.
The HEART workgroup, co-chaired by ONC, has run for about two years and delivered its mandate as much as it can absent participation by providers. So far, neither SMART, nor Argonaut, nor CMS BlueButton on FHIR, nor VA, nor All of Us, nor any major HIPAA Covered Entity has seen fit to participate in HEART. As a result, a user-directed exchange experience is not available to patients to match the way Open.Epic already allows live API access to over 60 medical centers.
In conclusion, let’s give ONC high marks for trying and hope the final version of TEFCA and subsequent enforcement will provide a patient-directed exchange user experience that makes the government-controlled exchange alternative compete for the patient’s trust. Some of these questions might be answered at the next ONC informational webinar on January 19. Comments on the draft TEFCA are open until February 20.
A blistering attack by the national editor of the New England Journal of Medicine against the “less is more” movement in medicine omitted that the publication’s former editor-in-chief played a foundational role in popularizing the idea of widespread medical waste.
The commentary in late December by Dr. Lisa Rosenbaum, “The Less-Is-More Crusade – Are We Overmedicalizing or Oversimplifying?” has attracted intense attention. Rosenbaum berates a “missionary zeal” to reduce putative overtreatment that she says is putting dangerous pressure on physicians to abstain from recommending some helpful treatments. She also asserts that the research by Dartmouth investigators and others who claim 30 percent waste in U.S. health care, in which she once fervently believed, is actually based on suspect methodology.
What Rosenbaum fails to mention is that the policy consensus she seeks to puncture – that the sheer magnitude of wasted dollars in U.S. health care offers “the promise of a solution without trade-offs” – originated in the speeches, articles and editorials of the late Dr. Arnold Relman, the New England Journal’s editor from 1977 to 1991.
Waste’s “fundamental cause is doctors”? Although Relman consistently blasted a variety of culprits who “commercialized” medicine, he was clear in a 1985 article for the National Academy of Sciences that “more prudent choices by physicians” would substantially reduce costs.
A “solution without trade-offs”? Relman could have been the poster child for that position. In a 1991 article for Health Management Quarterly, he wrote: “At least a third of all the money we now spend on medical care in this country could be eliminated…[and] we could afford to do everything medically appropriate for all our people,” including coverage of the uninsured.
Flawed research? Relman’s waste estimates, though widely quoted, were essentially opinions reified by his rank. As such, his figures fluctuated. Waste was “at least 15 to 20 percent” in that 1985 article. It was “20 percent” in a 1988 interview with me. “As much as 20 to 30 percent” in a 1990 New England Journal editorial. And in 1991, as noted above, “at least a third.”
I know the history of this effort because I covered it as a journalist, researched the quality movement for a peer-reviewed book and have continued to be active in this field as adjunct faculty at Northwestern University. For this article, I went back to the literature and my notes to confirm my memories. The “30 percent” waste figure came from Relman, and others (including the Institute for Healthcare Improvement, employer groups, policymakers and Dartmouth) took it from there.
On a personal note, while Relman’s guesstimate was a great soundbite, I deliberately omitted it from my book, Demanding Medical Excellence, since one of the book’s tenets was the flaws of eminence-based, rather than evidence-based, medicine.
Why does it matter that the New England Journal omitted its role in every aspect of a movement its national editor denounces? While the omission may not affect the debate over Rosenbaum’s core assertions, it does raise questions about the editorial standards of one of most trusted medical journals in America. Put bluntly: are there professional standards for criticism, or does it depend upon who is being criticized?
I suggest the Journal’s editors follow the mantra, WWJD. Not “What would Jesus do?” but “What would journalists do?”
Your national editor launched a sustained attack against activities your former editor-in-chief inspired, engaged in and, although not in every detail, supported in your publication. Since Rosenbaum’s commentary claims to be research-based, this seems an important piece of data not shared with readers. How was it missed?
There’s another, less likely but more disturbing possibility. Rosenbaum, referring to the less-is-more movement, writes that the more coherent a story seems, the more believable it becomes whatever the evidence might say. That inevitably opens the question of whether the omission of Relman’s role was an attempt by the writer or editors to make Rosenbaum’s attack piece more coherent.
And that leads to the matter of language. A top-tier medical journal allowed its national editor to suggest that those with whom she disagrees are not only misinformed on the facts, but zealots who persecute their fellow doctors, pervert policy and injure patients. Do the editors believe that’s an appropriate manner to characterize their own former editor? If so, by all means run a correction saying that Relman, and the Journal itself, should have been included among Rosenbaum’s culprits.
Or, forced to look in the mirror, might the editors rethink whether, indeed, “less is more;” i.e., there’s a need for less invective and incitement masquerading as iconoclasm and more reasoned argument.
My layman’s diagnosis is that Rosenbaum, a smart and talented writer, was suffering from Sage Syndrome, a condition afflicting those whose pay, prestige and pride are linked to the perceived profundity and cleverness of their opinions. I suspect Rosenbaum relied on her memory, which was flawed, and her editors were no better. Because her put-downs were proffered in defense of deference to status-quo physician behavior and the general goodness of doctors, her editors gave her pejoratives a pass, possibly rationalizing that being “provocative” would “drive web traffic.”
Those of us who believe in continuous quality improvement would call this an opportunity for a respected individual and institution – and Rosenbaum and the Journal are deservedly that — to undertake some honest self-examination.
When I worked at the Chicago Tribune, I was active in the national Society of Professional Journalists. I know that the newspapers that are of the caliber in their field of the New England Journal in its field would unhesitatingly choose to be tough on themselves and transparent with their readers. That’s what journalists would do. What path will Rosenbaum and the New England Journal take?
The Commonwealth of Kentucky, best known for its weirdly colored grass, fine bourbon and equestrian pageantry, is about to be destroyed by the Trump administration. Many will suffer and perhaps die because Kentucky obtained a Medicaid waiver to impose additional and often insurmountable hardships on poor people receiving their free health care from the State. Since all I need to know, I learned on Twitter, allow me to share with you some illuminating insights from the Twitterati.
The evil Republican Governor of Kentucky, Matt Bevin, is salivating at the prospect off changing Medicaid as we know it, which obviously means that poor people and especially people of color will be suffering greatly under this plan. You really don’t need to know more, since this should be reason enough to mobilize the worried wealthy, who are tossing and turning in their featherbeds night after night, searching for ways to save the poor. For those who are neither worried nor wealthy enough to really care, here are the ominous provisions of the Kentucky racist, homophobic and xenophobic plan to change Medicaid (it is all these things because it was not only approved, but encouraged by the Trump administration, and we all know what that means).
The most egregious transgression in the Kentucky HEALTH plan is the imposition of work requirements on Medicaid beneficiaries. The first thing that comes to my mind when they say “work requirements” is that sign at the entrance to Auschwitz saying that work makes you free. In Kentucky, the Republicans argue that work makes you healthy. Same thing. So, what are those monstrous work requirements? Medicaid recipients who are not children, who are not below the poverty line, who are not elderly, who are not pregnant, who are not disabled, who are not medically or mentally frail, who are not providing care to children or other disabled individuals, who are not experiencing hardships such as domestic abuse or homelessness or other disruptions in their lives, must spend approximately 4 hours a day in school (any school), training (any training), apprenticing, acquiring useful skills, volunteering in the community, searching for a job or actually working somewhere.
Wait, wait…. Don’t raise your eyebrows and don’t think or say anything. If you are reading this, you are most likely rich, likely white, well-educated and perhaps even male. Medicaid beneficiaries are none of these things. We all know that any of those endeavors could be truly insurmountable hardships for people who are poor, black or Hispanic, uneducated and female. We know that because we are not racists, misogynists or just plain bigoted SOBs, like the Republicans running Kentucky and that insufferable man running the country (or so he thinks).
Besides, most Medicaid beneficiaries who don’t fall in the exempt categories are already working. The ones who don’t work, or study, or do anything beneficial for themselves or others, are experiencing circumstances beyond their control. Helping them gain control over their lives is not Medicaid’s job because health and wellbeing have nothing to do with socioeconomic circumstances. And even if Kentucky wanted to “nudge” people into, say, getting their GED by funding a special rewards account, the bureaucracy involved in tracking all sanctioned activities, all exemptions and special circumstances is just too daunting for “these people” to navigate. Trust me on this one, I read it straight from the keyboards of Hollywood celebrities and several current and former big health care executives.
The second affront to humanity in the Kentucky plan is to charge poor people premiums for health insurance. Not only that, but those who can’t pay the premiums may be kicked off Medicaid. Granted the premiums range from $1 to $15 (in lieu of regular copays), and all the exemptions for ill health, frailty and poverty do apply here as well, but that still leaves a sizeable number of poor people who could be denied medical care just because they forgot to pay the monthly dollar twice in a row, or couldn’t afford the higher premium. These highly discriminatory practices targeting the poor are unheard of in other industries or even in the commercial segment of health care itself, where insurance premiums are largely voluntary.
To be fair to Kentucky, there is a mechanism by which people who did not pay their premiums on time can regain their Medicaid coverage, which brings us to provisions reminiscent of the Jim Crow days in the South. The Kentucky plan, you see, has a literacy provision for regaining access to care. This is obviously targeted at people of color and immigrants from what the GOP Leader calls “shithole” countries, which as every wealthy person in Bel Air knows, cannot read or write, and as evidenced by the thumbprint (or large X, depending on the State) appearing on most Medicaid applications. I have zero doubt that the Attorney General of the State of California will be taking the depraved Governor of Kentucky, and the Trump administration that enabled him, to court, and I have no doubt that the 9th Circuit Court of Appeals will find in favor of justice and equality, as it always does.
Until then, it seems that some Medicaid beneficiaries in Kentucky may have to sit through torturous health literacy or financial literacy classes, where they teach boring stuff about how to deal with debt, how health insurance works and how one can navigate these treacherous waters. There is no mention of a test or anything at the end, but this still seems like an unwarranted and blatantly racist imposition on “these people”. Even more outrageous though is that Kentucky is providing incentives, which can be used to purchase gym memberships, for Medicaid beneficiaries to take other classes, such as chronic care management or nutrition or drug addiction coping skills. What do illiterate people, drug addicts and all “these people” need gym memberships for? It’s like telling them to “eat cake” ….
And on and on goes the Kentucky HEALTH plan, listing one offensive section after another. The problem with this plan, which will live in infamy until the Sun goes supernova, is the cold, heartless and blatantly racist assumption that people who need Medicaid are as capable of functioning in modern society as anybody else. It ignores decades of teachings. It ignores hundreds of years of slavery and Anglo Saxon colonialist supremacy. And it ignores basic Christian values, because Jesus didn’t just sit there giving classes on how to fish. He gave people fish, and it worked great for Him and for His followers, eventually. If you see yourself as the Lord and Savior of huddled masses, you will want to do what Jesus did. If you feel equal to people who need Medicaid, but perhaps a bit luckier at this moment, you will dismiss everything I wrote here as total bullshit.
Last week at Health 2.0’s Wintertech, held during “health care’s money week” JP Morgan in San Francisco, Cambia CEO Mark Ganz gave a remarkable talk–one you wouldn’t expect from the leader of a big health insurer. He called out pharma for price gouging, he asked what consumers would think about the conversations we are having, but mostly he asked people to think about why they were working in health care. And he did it with a deeply personal set of stories. Everyone there found it very moving and very important, so I wanted to share it with the THCB audience. It’s well worth your time to watch. — Matthew Holt
Mike Magee When America’s politicians and business leaders elected to promote a free-enterprise approach to health delivery services in the immediate post-WWII period, they were choosing a course diametrically opposed to not only our Allies, but also our enemies at the time. We rejected serious health care planning. Instead we chose to directly and indirectly […]
It’s happening across many parts of the federal government, in many sectors. Officials of the National Park Service have been reprimanded for tweeting about climate change. Scientists at the Centers for Disease Control (CDC) have been warned away from seven specific words in their budget documents, including “fetus,” “evidence-based,” and “transgender.”
It is happening in healthcare as well. In previously secret proceedings, revealed here for the first time, representatives of organizations and companies across healthcare are in negotiations with a cross-agency team at Health and Human Services to restructure the language we use around medicine and healthcare.
This is being done for the good of the industry, its regulators and payers, and ultimately of course of the American people. And the industry. In fact, this will impact the industry in multiple ways, not the least of which is clarifying and easing the labors of those of us in the pundit and panjandrum crowd.
Honesty in labelling and punditry
After all, those of us who are dedicated to fixing healthcare first have to talk about it properly. We have to be sensible, straightforward, and honest in our discussions.
Take, for instance, “overtreatment,” which can now be re-labelled “medical exuberance.” “Unnecessary” tests and procedures will be called “recreational,” while the tenth MRI for the same problem will be referred to as “just dialing in the range.”
We can quit talking about the over $1 trillion per year we spend on these recreational tests and procedures as “waste,” and refer instead to healthcare as “America’s vital job creation engine.” People like jobs. The new healthcare slogan writes itself: “We turn medical exuberance into jobs.”
“Epidemics,” in which particularly popular disease states “go viral,” can be re-framed as “population-based marketing trends.”
We can trade the pejorative term “upcoding” for “opcoding,” as in “opportunity.” And “fee-for-service,” which is getting such a bad rap these days from the panjandrum crowd, can now be called “streamlined menu-based payment,” kind of like a Chinese restaurant. Instead of “one from Column A, and two each from Columns B and C,” we can just say, “This whole column. All the columns. And the desserts on the next page.”
“Overcharging” vs “Value Enhancement”
It has become blatantly obvious that slapping the label “overcharging” on the common and useful business practice of charging ten times as much as the shop down the road for, say, a new knee or a remodeled heart is a downright Orwellian twisting of language for political ends. The more reasonable and neutral replacement term is “value enhancement.”
This is eminently logical. The economist’s definition of the value of anything is “what an informed buyer will pay for it.” If you (or some payer on your behalf) paid $115,000 for a new knee while some other poor loser only got to pay $17,500 for the same implant, the same institution, the same surgical and rehab teams, clearly you have a lot more value packed into that titanium baby. And you were informed about it, at least after the fact, when the six-foot-long bill in six-point dot matrix type finally showed up in the mail.
Your $115,000 new knee is clearly something to brag about. Does anyone order a new Mercedes to be delivered without the three-pointed star in a circle on the hood? I don’t think so. The liver transplant doc who lasered his initials on the livers he put in? Forget that, you’ll want the doc’s logo tattooed right on the outside of the knee, just like those folks who leave the “Armani” or “Zegna” tag on the sleeves of their suits and keep checking the time so that you can see their Rolex. Maybe the surgeons can re-engineer one of the skin flaps you keep growing into a cute little all-natural price tag that will wave around merrily as you get back to dancing around the racquetball courts.
“Organic” vs. “primitive” medicine
As different styles of medicine emerge, we will have to think carefully about how we label them. Remember when the first hospitals to open departments of “Nuclear Medicine” were met by angry crowds of citizens bearing pitchforks and petitions—when the practice in fact had nothing to do with nuclear reactors or nuclear weapons?
What should we call diagnostics and therapies derived from big data troves and imbedded sensors put through AI wringers and deep-learning algorithms popped through CRISPR machines to deliver personalized RNA medicine? We will callthat style “real” medicine or “organic” medicine.
In contrast, medicine derived from intense personal consultation with a physical human doctor who actually knows you, your lifestyle, and your stage in life, and actually touches your body and subjects it to thoughtful testing, will be called “primitive” medicine.
And life expectancy? What about the fact that for every 10 million people who drop insurance because it would cost them more than the roof over their head, we get 10,000 extra premature deaths? We can just call that “market-adjusted longevity.” People choose what they choose, and they are free to. This is America!
Even calling them “premature” deaths is overly argumentative and political. If people want to die earlier than some government actuary thinks they should, why should we give their deaths a pejorative label? Rather than “premature deaths,” we’ll call them “opt out deaths.” Ten thousand, 20,000, 40,000 “opt out deaths” (OODs) per year actually represent the ultimate consumer choice. The new metric will be KO/A, that is kilo-OODs/annum. As in, “This bill will result in a quite nominal 35 KO/A, a number the committee feels comfortable with when we consider the net present value of the ROI to the GDP resulting from consumers exercising their ultimate free choice to permanently de-access the market.”
There are of course multiple well-meaning groups working tirelessly to eliminate this precious consumer choice. We have to acknowledge that. But calling the schemes they propose “universal” or “single payer” or even “Medicare for all” is blatantly contentious. We will prefer a more neutral, descriptive term such as “forced march” healthcare.
Acronym Control (AC)
It is widely agreed that acronyms must be brought under control. This inter-agency effort will be coordinated by a new office within the CMS of HHS called the ACA Agency for Control of Acronyms (ACA), known more simply as (HHS(CMS(ACA2))). Programs and agencies that lose their own acronyms will have to fall back on the generic OWA (Other Weird Arrangements).
The communication of quantum financing
Many of the seemingly intractable problems at the core of healthcare are really problems of communication. For instance, over the past few decades, America’s hospitals and clinics have bravely pioneered the use of quantum financing. But they have not sufficiently explained this to their patients, their patients’ families, and the executors of their patients’ estates. We as an industry have to get straight with the public and clearly lay out the theory and the facts of, for instance, Schrodinger’s networks, in which the surgeon that you hired to rebuild your sterno-thoracic cavity is definitely both in your network and out of network at the same time. He or she will not collapse into one state or the other until the moment you rip open the bill they send you afterwards.
Similarly, we will see a big leap in price transparency when we understand the application of Heisenberg’s Uncertainty Principle, which has long existed as an undergirding axiom of hospital finance. For example, you might be able to discover just which items you might be charged for in a given procedure, within a reasonably narrow curve of probability. You might be able to discover exactly how much each item cost at some indeterminate point in the past. You may well be able to discover what an operation like yours cost somebody else last year, or this year in some other state. But if you were to somehow discover exactly what your operation will cost you in this institution this year, your knowing that would collapse space-time as we know it and annihilate at least the institution or possibly even the entire healthcare sector.
We can anticipate ever greater clarity as the science proceeds. The biggest, deepest cosmological conundrum has long been: How can the universe exist at all? If matter and anti-matter arise randomly and in equal amounts as theory suggests, and they continually combine and annihilate one another, why is there so much more matter than anti-matter in the universe, enough to build planets and stars and forceps and Senators?
When cosmologists and physicists resolve this core problem, I think we will find the answer to the analogous problem in healthcare: Why, with all the discounts and special prices and risk-sharing and all this maniacal curve-bending going on, does healthcare continue to cost more every year, gobbling up more and more of the economy? And the corollary question: At what point does healthcare get so large and eats up so much of the resources available to it that it begins to eat its own tail and soon disappears completely with a barely audible “pop”?
These are serious questions.
After all, the whole healthcare system is derived from evidence-based economic science “in consideration with community standards and wishes” as the CDC directive helpfully suggests.
Which begs the question: Which community? Whose fine standards and wishes are being considered and weighed with the available evidence? A close examination of the design of the vast agglomerated healthcare sector suggests that it’s the warm and charming community of shareholders, bondholders, entrepreneurs, and executives. And of course us, the pundits, podium poohbahs, and grand panjandrums, who will not be out of work for a long long time. Whether we like it or not.